The Diagnostic and Statistical Manual published by the American Psychiatric Association

Overview

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is an American handbook for mental health professionals that lists different categories of mental disorder and the criteria for diagnosing them, according to the publishing organization the American Psychiatric Association. It is used worldwide by clinicians and researchers as well as insurance companies, pharmaceutical companies and policy makers. It has attracted controversy and criticism as well as praise.

There are five revisions of the DSM since it was first published in 1952. The last major revision was the DSM-IV published in 1994, although a "text revision" was produced in 2000. The DSM-V is currently in consultation, planning and preparation, due for publication in approximately 2012.[1] The mental disorders section of the International Statistical Classification of Diseases and Related Health Problems (ICD) is another commonly-used guide, and the two classifications use the same diagnostic codes.

History

The Diagnostic and Statistical Manual of Mental Disorders was first published in 1952, by the American Psychiatric Association. It was developed from an earlier classification system adopted in 1918 to meet the need of the federal Bureau of the Census for uniform statistics from psychiatric hospitals; from categorization systems in use by the United States military; and from a survey of the views of 10% of APA members.[2] The manual was 130 pages long and contained 106 categories of mental disorder. The DSM-II was published in 1968, listed 182 disorders, and was 134 pages long. These manuals reflected the predominant psychodynamic psychiatry.[3] Symptoms were not specified in detail for specific disorders, but were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions appearing disconnected from reality). Sociological and biological knowledge was also incorporated, in a model that did not emphasize a clear boundary between normality and abnormality.[4]

In 1974, the decision to create a new revision of the DSM was taken, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members.[5] One goal was to improve the reliability of psychiatric diagnosis. The practices of mental health professionals, especially in different countries, was not uniform. The establishment of specific criteria was also an attempt to facilitate mental health research. The multiaxial system attempts to yield a more complete picture of the patient, rather than just a simple diagnosis. The criteria and classification system of the DSM-III was based on a process of consultation and committee meetings. An attempt was made to base categorization on description rather than assumptions of etiology, and the psychodynamic view was abandoned, perhaps in favor of a biomedical model, with a clear distinction between normal and abnormal.

The criteria adopted for many of the mental disorders were expanded from the Research Diagnostic Criteria (RDC) and Feighner Criteria which had been developed for psychiatry research in the 1970s. Other criteria were established by consensus in committee meetings, as determined by Spitzer. The approach is generally seen as “neo-Kraepelinian”, after the work of the psychiatrist Emil Kraepelin. Spitzer argued that “mental disorders are a subset of medical disorders” but the task force decided on the DSM statement: “Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome.” The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced. Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, such that the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless “neurosis” was included in some capacity, a political compromise reinserted the term in parentheses after the word “disorder” in some cases. In 1980, the DSM-III was published, at 494 pages long and listing 265 diagnostic categories. The DSM-III rapidly came into widespread international use by multiple stakeholders and has been termed a revolution or transformation in psychiatry.[3][4]

In 1987 the DSM-III-R was published as a revision of DSM-III, under the direction of Spitzer. Categories were renamed, reorganized, and significant changes in criteria were made. Six new categories were deleted while others were added. Controversial diagnoses such as pre-menstrual dysphoric disorder and Masochistic Personality Disorder were considered and discarded. Altogether, DSM-III-R contained 292 diagnoses and was 567 pages long.

In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a three step process. First, each group conducted an extensive literature review of their diagnoses. Then they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative. Finally, they conducted multicenter field trials relating diagnoses to clinical practice.[6][7] A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required that symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.

A "Text Revision" of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged.[8] The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes in order to maintain consistency with the ICD.

Referencing the DSM in APA Format

First time referenced: ". . . according to the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV-TR], the standard reference text for psychiatric diagnoses (American Psychiatric Association, 2000)."

DSM and politics

Following controversy and protests from gay activists at APA annual conferences from 1970 to 1973, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After talks led by the psychiatrist Robert Spitzer, who had been involved in the DSM-II development committee, a vote by the APA trustees in 1973, confirmed by the wider APA membership in 1974, had replaced the diagnosis with a milder category of "sexual orientation disturbance". This was replaced with the diagnosis of ego-dystonic homosexuality in the DSM-III in 1980, but this was removed in 1987 with the release of the DSM-III-R.[3][9][10] A category of "sexual disorder not otherwise specified" continues in the DSM-IV, which may include "persistent and marked distress about one’s sexual orientation”.

The current DSM

Categorization

The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states that “there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries...” but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance.[11] Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:

Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders

Axis II: underlying pervasive or personality conditions, as well as mental retardation

Axis III: Acute medical conditions and Physical disorders.

Axis IV: psychosocial and environmental factors contributing to the disorder

Cautions

The DSM-IV-TR states that, because it is produced for mental health specialists, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”.[12] The APA notes that diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises that laypersons should consult the DSM only to obtain information, not to make diagnoses, and that people who may have a mental disorder should be referred to psychiatric counseling or treatment. Further, people sharing the same diagnosis/label may not have the same etiology (cause) or require the same treatment; the DSM contains no information regarding treatment or cause for this reason. The range of the DSM represents an extensive scope of psychiatric and psychological issues, and it is not exclusive to what one may consider “illnesses”.

DSM-IV sourcebooks

The DSM-IV doesn't specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials.[13][14][15][16] The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.[17][18]

DSM-V planning

The DSM-V is tentatively scheduled for publication in 2011.[19] In 1999, a DSM–V Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-IV,[20] and the resulting work and recommendations were reported in an APA monograph[21] and peer-reviewed literature.[22] There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children.[23] The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.[24]

On July 23rd 2007, the APA announced the task force that will oversee the development of DSM-V. The DSM-V Task Force consists of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM have experience in research, clinical care, biology, genetics, statistics, epidemiology, public health and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members'disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. Revision of the DSM will continue over the next five years. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions.

Criticism

There have been a number of persistent critical debates concerning the DSM.

There has been continuing scientific debate concerning the construct validity and practical reliability of the diagnostic categories and criteria in the DSM, even though they have been increasingly standardized to improve inter-rater agreement in controlled research.[25][26][27] It has been argued that the DSM's claims to being empirically founded are overstated in general.[17]

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. Although the DSM-IV may move away from this categorical approach in some limited areas, some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.[28][29][30][31]

It has been argued that purely symptom-based diagnostic criteria fail to adequately take into account the context in which a person is living, and whether there is real internal disorder of an individual or simply a response to an ongoing situation.[32][33] It is claimed that the use of distress and disability as additional criteria for many disorders has not solved this false-positives problem, because the level of impairment is often not correlated with symptom counts and can stem from various individual and social factors.[34]

The political context of the DSM is a topic of controversy, including its use by drug and insurance companies. The potential for conflict of interest has been raised because roughly 50% of the authors who previously selected and defined the DSM psychiatric disorders have had or have financial relationships with pharmaceutical industries and drug companies.[35] Some argue that the expansion of disorders in the DSM has been influenced by profit motives and represents an increasing medicalization of human nature,[36] while others argue that mental health problems are still under-recognized and under-treated.

Some people diagnosed with "Gender Identity Disorder" and some people with pedophilia criticize the DSM. They cite the APA's decision to remove homosexuality from the DSM as evidence that the APA incorrectly refers to many diverse states of being or orientations as mental illnesses.[37]